So your next exam question is about a recent immigrant... 3 things to know
In case you work in a practice with very little ethnic diversity (like some places in Canada that I have lived), you may not be well-prepared to manage a patient who is a recent immigrant. The exam does cover immigrant health, though, and you want to be sure you are able to take care of these patients in accordance with the most recent immigrant health guidelines.
Be sure your management includes the following:
VACCINES SAVE LIVES
Assess Vaccination Status. Better yet, if there’s any doubt about the patient having received MMR or DTP, just give the vaccine. As many as half of all immigrants are not immune to MMR or DDP and the most recent guidelines on immigrant health recommend not even testing for these: just give the vaccine if you have any doubt about the patient’s immune status. (This doesn’t apply to Varicella & HBV, however – consider testing before vaccinating for these. See the immigrant health guidelines for more info).
TO SCREEN OR NOT TO SCREEN?
Screen for depression. The Immigrant Health guidelines recommend screening for depression (which actually conflicts with the Canadian Task Force for Preventive Health Care guidelines which recommend NOT screening for depression in asymptomatic patients). If this comes up on an exam this would be the way to answer this question for a non-immigrant, especially because this clinical practice guideline was endorsed by the CFPC who write your exam.
If you choose to screen, a two-question technique can be helpful (for more info see the Canadian Guidelines on MDD):
“In the last month, have you been bothered by little interest or pleasure in doing things?”
“In the last month, have you been feeling down, depressed or hopeless?”
MORE SCREENING CONUNDRUMS
The most recent Immigrant Health guidelines recommend AGAINST screening for child maltreatment, PTSD, or domestic violence (unless the patient is high risk) – the current evidence simply doesn’t convincingly show that the benefits of screening outweigh the possible harms.
EXPAND YOUR DDx
What Else Could It Be? A patient who presents with a cough and was born and raised in Canada has a very different differential diagnosis than a patient who just arrived from a TB-risk country. Though it seems obvious now, it’s easy to miss unless you ask yourself, “What else could this patient have?” In fact, the guidelines recommend that any immigrant from (or traveler to) Southeast Asia or Africa who presents with vague abdominal symptoms should be tested for Syrongyloidiasis. Though you may have never heard of this, this is an incredibly common parasite that we tested nearly everybody for when I did an elective at a Tropical Disease Unit. The bottom line is this: you don’t have to know the complete and lengthy differential diagnosis of symptoms in an immigrant, but if your treatment isn’t working or if you're unsure, be willing to consult a travel medicine or infectious diseases colleague early on in your management (or on an exam be sure to state you’d consult one).
PEARLS FOR PRACTICE: Next time you order H. Pylori or celiac testing in a patient with vague abdominal symptoms, ask yourself, “Has this patient been to Southeast Asia or Africa?” If so then don’t forget to write “strongyloidiasis serology” on your lab req!